Trouble in the southwest for psychiatric patient

[mswphysician]

Has anyone heard of the troubling news coming out of New Mexico and Louisiana? In New Mexico, psychologists (who are not medical doctor nor do they have medical training of any sort) are being allowed prescription rights comparable to trained, board certified psychiatrists and other physicians. In order to procure this right, the psychologist (Ph.D. or Psy.D.) must take several courses (not at the medical school level), be supervised by a physician for a short period of time, and take a licensure exam. The only bright side to this catastrophe is the state medical board is to design and implement the courses, supervision, and develop the licensure exam.

Even more troubling, in Louisiana (where the measure has passed the house and the senate) the state board of psychologists has proposed it has the authority and knowledge to train, set standard, develop licensure requirements, etc. for psychologists to practice what is essentially psychiatric medicine. Additionally, the psychologist would only need 100 hours of "supervised" time before they could prescribe. Psychologist would also be required to attend classes that, to paraphrase Dr. Marcia Goin (president of the APA), falls woefully short of medical school.

After reading several articles and reports on this subject, I looked at both the AMA and AOA websites for a response and hopeful advocacy from the groups. There was nothing that I could find addressing this issue. When I went to the APA website, there is a letter written to Louisiana governor urging the veto of the bill if it passes.

Now, why should we care? You may not be interested in psychiatry as a profession. After being a social worker for six years I certainly am not. This to me is not the point. Adequate medical care is. As medical doctors, no matter what the specialty, we will treat the mentally ill. By going into medicine we are required to advocate for all patients by keeping the standards of care high for all, including the mentally ill. If these psychoactive drugs (including clozaril, haldol, Thorazine, as well as the atypicals, SSRI's and controlled substances) are so benign, why not make them over the counter? If training medical doctors to deal with people who have psychiatric conditions is so pedestrian, why have residency? Why not hold physicians to the same standard as proposed by the psychologists? for that matter, why not allow MSW's, PA's, NP's, RN's the ability to take the same course work and have unsupervised prescriptive powers?

To me, the disregard for proper training in medical mental health further reinforces the notion that psychiatry and those with psychiatric conditions do not suffer from biological diseases and therefore do not need trained medical doctor treating them.

I end my rant with a call for all MD's and DO's to put aside bickering over who has the better degree and focus on the real and tangible threats to our patients. Get active. Write the AMA AND AOA and encourage more advocacy for patients and their safety.

Please reference the American Psychiatric Association: www.psych.org and the American Psychological Association www.apa.org

Here is a letter on the APA's web site, please note all dates:
DATE: May 3, 2004

TO: LPMA Members

FR: Patrick O?Neill, M.D.
Dudley M. Stewart, M.D.

RE: YOUR CALLS OPPOSING PSYCHOLOGIST PRESCRIBING BILL ARE STILL NEEDED

ACTION REQUESTED:
USE THE TOLL-FREE NUMBER TO CALL GOVERNOR BLANCO; ASK HER TO VETO HB 1426

Louisiana Governor Kathleen Blanco has until May 6 to veto House Bill 1426, legislation to allow psychologists to prescribe psychotropic medications. If Governor Blanco does not veto the bill by that date, HB 1426 will become law, even without her signature.

LPMA, in partnership with LSMS, APA, and AMA, with strong support from patient groups, has worked tirelessly to persuade Governor Blanco to veto this threat to the health and safety of Louisiana patients.

PLEASE HELP US PERSUADE GOVERNOR BLANCO TO VETO THIS BILL. Your calls are needed NOW so that she knows that there is strong opposition to HB 1426. Use the toll-free number below to call Governor Blanco and let her know that Louisiana physicians and their patients don?t want this dangerous bill to become law.

Call the governor?s constituent services line toll-free at 800-317-5918.

Your suggested message:

?As a psychiatric physician, I ask you to veto House Bill 1426, the psychologist prescribing bill. Our patients deserve the very best health care. This bill is a prescription for disaster. Please veto HB 1426.?

Thank you for your continued personal support of LPMA?s efforts on your behalf. Please contact LPMA at 504-891-1030 for additional information.

---

Members don't see this ad.

 

[Gauss]

let them prescribe
and incur all responsibility for it
They'll need malpractice insurance, which they won't be able to afford
There's more smoke than fire here
I suspect it will be impossible to implement

 

[Super Rob]

How do you think the drug companies feel about this?

 

[mswphysician]

How do you think the drug companies feel about this?

happy as pigs in slop

 

[beriberi]

More psychoactive drugs are prescibed by primary care doctors than psychiatrists. There are many parts of this country where there is no available psychiatric care (like most of the counties in New Mexico and Louisiana). Good psychologists will know this limits of their scope of practice (i.e. prescribing antidepressives but not antipsychotics). Honestly, many FPs, OB-GYNs, IM doctors are prescribing these drugs with much less training in psychiatry/psychology. (I know this, because in 3 short weeks, I will have the ability to prescribe any drug I want, and I don't feel that I have 100 hours on psychopharmacology.)

An aside: what is a medical school level course? I have had courses in medical school that were less challenging than college courses. Unless you have specific information about poor quality/objectives, this is a silly criticism. Additionaly, I believe you have to be PhD level to take the courses/get the certification.

I think that what is best for patients is having access to mental health care. If psychologists are dealing with uncomplicated depression, there is more room for the psychiatrists to deal with more complicated cases. Pragmatically, this is a great solution.

Quit whining and think about how to *help* people.

 

[Anasazi23]

An aside: what is a medical school level course?...Unless you have specific information about poor quality/objectives, this is a silly criticism.

A medical school level course is not but one course. It is a compendium of courses that enables the student to obtain a comprehensive understanding of human anatomy, physiology, biochemistry and their interrelatedness. None of this is obtained in psychology prescribing school.

I think that what is best for patients is having access to mental health care. If psychologists are dealing with uncomplicated depression, there is more room for the psychiatrists to deal with more complicated cases. Pragmatically, this is a great solution.

So what you'd like is for psychologists to see uncomplicated 15 minute depression cases, and the psychiatrists to see 45 min to 1 hour complicated cases, which will inevitably be billed the same. Why don't you just ask for the elimination of the psychiatric profession altogether?

If you bothered to do ANY research, you'd see that these proposals were originally designed so that prescribing psychologists would move to "underserved areas" to provide services to these populations. As you might expect, studies indicate that they have not done this - they remain in cities and more urban areas.

Quit whining and think about how to *help* people.

You are a complete *****....
This effects all physicians, not just psychiatrists. Your altruistic line might have got you into med school, but you'll need to come up with more logical arguments and bother to think about the politics of medicine to be an effective physician.

 

[beriberi]

A medical school level course is not but one course. It is a compendium of courses that enables the student to obtain a comprehensive understanding of human anatomy, physiology, biochemistry and their interrelatedness. None of this is obtained in psychology prescribing school.

Here is a quote from the press release when the law was signed into effect:

New Mexico House Bill 170 recommends a prescription training program based on a proven model used by the Department of Defense to train psychologists in the military to prescribe psychotropic medications for their patients. To receive a prescribing license in New Mexico, psychologists must complete at least 450 hours of coursework; a 400 hour/100 patient practicum under physician supervision; and pass a national certification examination. The academic component includes psychopharmacology, neuroanatomy, neurophysiology, clinical pharmacology, pharmacology, pathophysiology, pharmacotherapeutics, pharmacoepidemiology, as well as physical and lab assessments.

Again, that is way more than I have had in pharmacology training. Way, way more than my top medical school provided. In addition, the first two years of prescribing will be done under a physician's supervision. Which one could equate to residency. (Before you tell me I am an idiot, a lot of residencies do little teaching and supervision--though this may not be the same thing as a good residency, it is probably the same thing as a residency which meets minimum medical requirements.)

So what you'd like is for psychologists to see uncomplicated 15 minute depression cases, and the psychiatrists to see 45 min to 1 hour complicated cases, which will inevitably be billed the same. Why don't you just ask for the elimination of the psychiatric profession altogether?

Wow. You got that right. I think that different level providers serve different level patients well. (I am all for Nurse Practitioners treating strep throat, too.) The billing may not be fair. You should start a thread: "Billing is not fair." Then you could write about how billing should be based on time spent with a patient and not on procedures (isn't it funny when you think that we let surgeons design a billing system?). I wouldn't ever ask for the elimination of the psychiatric profession; who would spend 45 to 1 hour on the complicated cases? Also, my goal is to support policies which increase the general level of health in America.

If you bothered to do ANY research, you'd see that these proposals were originally designed so that prescribing psychologists would move to "underserved areas" to provide services to these populations. As you might expect, studies indicate that they have not done this - they remain in cities and more urban areas.

I didn't see a citation for the above "fact" and I don't trust you. I choose to infer that expanding the number of people who can provide basic psych care will expand the populations that have access to basic psych care.

You are a complete *****....
This effects all physicians, not just psychiatrists. Your altruistic line might have got you into med school, but you'll need to come up with more logical arguments and bother to think about the politics of medicine to be an effective physician.

Wow. I think that violates terms of service. Anyways, didn't your mother tell you not to call people names? I may be a "complete *****" but that does not invalidate/validate my argument. You (and this is not name-calling) make weak arguments that are based on self-preservation.

I think it is silly to assume I got into medical school saying that I want to help people (check out the pre-Allo forum--that is REALLY discouraged these days.) I think about the politics of medicine all of the time. And, I support changes in the status quo that meet my goals (more health care for more people). Maybe I will get more jaded and my goals will change to "more money for me, less competition for my ability to prescribe SSRIs." But, I think I will be just fine (it is the health care system that I am worried about).

 

[Gauss]

Honestly, many FPs, OB-GYNs, IM doctors are prescribing these drugs with much less training in psychiatry/psychology. (I know this, because in 3 short weeks, I will have the ability to prescribe any drug I want, and I don't feel that I have 100 hours on psychopharmacology.)

That's pathetic
Either your school is deficient or YOU are. Take on the responsibility to know those drugs, otherwise don't prescribe them.
I know plenty of IM/FP's that know a few of those drugs extremely well, are comfortable with them, and use them appropriately. They never had extensive psych training, and they don't need it.

If I hear one more pathetic whine about 'helping' people I'm gonna puke
grow up
at this point everyone has the same goal of helping people and it's obnoxious and insulting to even claim others don't share that same desire

 

[beriberi]

That's pathetic
Either your school is deficient or YOU are. Take on the responsibility to know those drugs, otherwise don't prescribe them.
I know plenty of IM/FP's that know a few of those drugs extremely well, are comfortable with them, and use them appropriately. They never had extensive psych training, and they don't need it.

I don't claim any deficiencies (for me or my school). My point is that we (as physicians) have a lot less training in psychopharmacology than these psychologists would have, under these programs. I "take on the responsibility to know these drugs" and plan on prescribing them. But I don't have 1000+ hours/training in psychopharmacology.

So, to claim that they don't know enough to prescribe them (as people are doing) seems silly, when they would have much more training that I do. As you point out, IM/FPs prescribe these drugs all of the time, very well, with little psych training. Like all drugs, psych drugs have risks and unwanted side effects. However, they can (and are) prescribed by many people, and are prescribed well. Adding well-trained PhD psychologists to the mix is not (in my opinion) a dangerous thing (and would benefit patients). We should not forget that untreated psychiatric disease has terrible sequellae (hmmm...did you know that the suicide rate is 75% higher in New Mexico than it is nationally?)

If I hear one more pathetic whine about 'helping' people I'm gonna puke
grow up
at this point everyone has the same goal of helping people and it's obnoxious and insulting to even claim others don't share that same desire

Nuance is lost on a lot of people. Anyways, As you may have noticed, Anasazi pointed out that helping people is just one of many "alturistic lines" that only belong on medical school applications. I think there are a lot of people out there whose focused has shifted to financial preservation.

 

[Anasazi23]

.... In addition, the first two years of prescribing will be done under a physician's supervision. Which one could equate to residency. (Before you tell me I am an idiot, a lot of residencies do little teaching and supervision--though this may not be the same thing as a good residency, it is probably the same thing as a residency which meets minimum medical requirements.)

wrong, wrong, and wrong.

Here's some more information you might find interesting:
"According to the curriculum, class meets every third weekend with 384 hours of classroom instruction is needed over two years. In the section titled ?Frequently Asked Questions,? it says students will have to spend two to three hours a week studying. The pamphlet also says the course is on a ?pass-no pass system,? meaning an average score of 70 percent is required to pass. If a student does not pass a class, the program will develop a plan to do remedial work and retake an exam

Also, my goal is to support policies which increase the general level of health in America.

...from the same website you got your course outline:
"The Psychiatric Association called that argument a Trojan horse, noting that the psychologists rejected proposals to limit prescribing privileges to psychologists located in under-served areas."

I didn't see a citation for the above "fact" and I don't trust you. I choose to infer that expanding the number of people who can provide basic psych care will expand the populations that have access to basic psych care.

Want a citation?
"Not only is there a lack of evidence that they will move to underserved areas, but they enjoy living in the same geographic areas that federal government statistics show are already "oversupplied" by physicians!
Psychiatric News July 5, 2002
Volume 37 Number 13
? 2002 American Psychiatric Association
p. 16

Care for another citeable opinion?
"The reality is the majority of the
workforce there is mid-level--a bachelor's-level social worker," says
Lambert. "You don't have a whole bunch of Ph.D. psychologists
practicing in rural America. This is not the magic bullet or a
solution in and of itself."
At the same time, Lambert points to four decades of largely
unsuccessful efforts to increase the number of both psychologists and
psychiatrists in rural areas...
2003, Congressional Quarterly, Inc.

I remember seeing the raw stats somewhere but I'll have to dig them up. Something to the effect of 5 psychologists moving to underserved areas whom are eligible.

...You (and this is not name-calling) make weak arguments that are based on self-preservation.

really? My arguments, which are largely the same as that of the american psychiatric association, and The Society for the Science of Clinical Psychology (SSCP), a section of the American Psychological Association, are essentially the same.

The following quote if from the president of the American Psychiatric Association, Richard K. Harding, M.D.:
"We believe that the legislature and the governor in New Mexico have placed patient health and safety at risk. . . . By virtue of their training and education, psychologists simply do not have the background or experience to safely and effectively use powerful medications in the treatment of mental illnesses. Psychologists have always had a clear path to prescribing privileges: medical school. No psychology-designed and administered crash course in drug prescribing can substitute for the comprehensive knowledge and skills physicians achieve through medical education and rigorous clinical experience. . . ."

Care to tell him that his are "weak arguments that are based on self-preservation?"

...more money for me, less competition for my ability to prescribe SSRIs." But, I think I will be just fine (it is the health care system that I am worried about).

This is an overreaching example of how you naively and falsely assume my view is to obtain more money and prescribe what are widely "safe" medications. You clearly have no comprehension of the field of psychiatry in particular, and I question your understanding of medicine in general.

You're worried about the "health care system?" If you fail to see the link between psychiatry being "threatened" by prescribing psychologists, and how that reaches into other medical paraprofessionals impacting patient care from an economic and personal standpoint, I urge you to do the relevant research.

 

[Anasazi23]

Interested people should check out this link:
http://home.earthlink.net/~jwb9/rxp_truth_squad/

 

[Gauss]

But I don't have 1000+ hours/training in psychopharmacology.

So, to claim that they don't know enough to prescribe them (as people are doing) seems silly, when they would have much more training that I do.

So what the hell were you doing during 2nd year pharm, boards, psych/neuro rotation, and other rotations????????
Just with your psych rotation you should have more than 1/2 that amount of hours of psychopharm exposure
I simply don't understand your argument that you are underqualified in psychopharm???
What more do you need?

 

[beriberi]

My second year pharm rotation ~30 class room hours (for general pharm principles)
second year psych pharm ~12 classroom hours

Studying for the boards--none of your business, and studying for a licensing exam is not the same thing as classroom hours

Neuro rotation, 4 weeks, no classroom hours regarding psych medications
Psych rotation, 4 weeks, approximately 16 classroom hours of psych med instruction. (Sure, I had 250 hours in the hospital, but we should all know that hours in the hospital are not always used for teaching).
Emergency medicine rotation, 4 weeks, approximately 2 hours psych med instruction (you didn't ask, but I am trying to be generous)

Now--we are up to: 60 classroom hours.

BTW, Anasazi, there is the course AND 2 years of supervised prescribing (where a physician is looking over your shoulder, approving prescriptions). It is the latter I compared to residency. The former is the part you were describing.

I have made my points. You have made the points of the American Psychiatric Association (which I must say, I could have guessed without the quotes what they had to say about all this).

 

[Boomer]

We're also ignoring the fact that psych meds interact with A LOT of other meds. Are these psychologists going to be trained to understand these interactions and how to deal with them? If so, how long until they want greater prescribing rights? If they simply need some cursory education in prescription drugs, why should they be limited to psychotropics only?

It seems counterproductive to train a counselor in the full amount of biochemistry and physiology (along with the pharm and path) necessary to prescribe meds. In fact, one could argue that it may infringe on their abilities as a pure counselor, which is what THEY chose to train for in the first place.

 

[Anasazi23]

But BeriBeri,

Contrary to what they would have you believe,even a large portion of the American Psychological Association is against prescription privilages for these and other reasons.

People say the slippery slope argument is invalid de facto. However, it just seems to happen so often that the slope is unavoidable. We see this with politics all the time.

Am I worried that psychologists will drag the problems associated with their profession into psychiatry, partially for selfish reasons? Of course. But do I also feel that this junior psychiatry program is the best way to treat psychiatric patients? Absolutely not.

How do you envision a world of healthcare 40 years from now when the majority of patients are seen by physician assistants, nurse practitioners, "primary care chiropractors," and the like? Meanwhile you, who have spent 100k, thousands of hours training, and are making 65k due the nationalized health care that president Hilary Clinton put into effect some 35 years ago in our hypothetical future are trying to make ends meet?

In other words, is this a matter of politics and the future of physicianhood? Yes. Also importantly, is this a matter of best patient care by the most qualified members of the health care team? A resounding yes.

 

[mswphysician]

beriberi- i respect your point of view, although, I truley do not agree with it. I feel the issue comes to competence. As a medical student, you have logged many hours in pharmocology of all drugs. Is it acceptable to disregard all drugs you do not prescribe on a routine basis? If so, how do family practice doctors in small communities act effectively seeing people of all different ages where anything can walk through the door?

Furthermore, as a medical student you were responsible for learning the psychiatric exam which is very much different from the psychology assessment. In psychiatry we are taught to evaluate all causes that may be seen as psychiatric. I will give you an example. Before I started medical school I worked as a medical social worker at a hospice. We were lucky to have a psychologist (Ph.D.) on staff. An elderly man was the primary caregiver for his wife (who was dying from cancer). The psychologist made multiple visits to the house of this couple and worked with them for several weeks. At one of the multiple team meeting the psychologist stated he was baffled because the elderly man had recently begun having visual hallucinations. The psychologist reported that he did a complete psychological assessment which revealed no psychotic symptoms prior to this episode.

Luckily, the medical director was at this meeting. He asked the psychologist if the pt had changed medication or begun anything new (along with other questions). The husband had not. Being a good physician, the medical director strongly encouraged the husband be sent to his primary care physician. After a complete workup including various scans, the husband was diagnosed with a brain tumor.

The point of this story is not to bash psychologists or say they are inferior to physicians. The point is that having a Ph.D. in anything does not train one for medicine. I have a close friend who does cancer research at Emory. He also has a Ph.D. in molecular biology. He knows much about multiple chemotherapy drugs, their mechanism of action, etc. Why should he not be able to treat patients with cancer? He is atleast trained in a scientific manner more in line with how physicians are trained.

Additionally, psychologists (even at the Ph.D. level) are not even required to have basic chemistry, let alone organic and biochemistry, or biology. Depending on their undergraduate degree, they may have had to take one semester of "science" which can be anything, like astronomy. How can you teach someone advanced courses in these subjects when they do not even have a basic understanding of them? Would you want you or someone you love being treated by someone who has taken advanced courses, but did not have a foundation to understand these courses? I would not. My preference. But most people have no idea what the difference is between psychologists and psychiatrists. And they should be informed.

As future medical doctors it is important to remember we do not know everything. We rely on others to provide us with important related information relating to care. It is our job to take this information and put it all together to develop care for a pt. Pharm. D.'s often know more about mechanism of drugs, etc. than physicians. Does this qualify them to prescibe? No, I do not think so. Not just out of snobbery, but out of the knowledge that medicine not just memorizing facts and understanding only your particular realm of treatment, but being able to receive multiple sources of data, understanding it, and putting it to use clinically. This is what makes medicine unique from other health care professions.

I have no problem if any profession, from social work to the culinary arts, wanting to prescibe. However, their education (starting at the undergrad level) continuing through thier Ph.D., MD, DO, Psy.D. (or whatever) should provide them with a basic understanding of science (mainly the chemistries and biologies) and progresses to more advanced science building on the basics, then clinical supervision using this knowledge, and post graduate training which allows the person to be in charge of a patient while still being supervised. Furthermore, thier lincensure test should be at the same level as a profession that has been treating people for many years. Then I feel they have the knowledge and experience which gives them the unsupervised, unrestricted presciption right.

As to my use of the term medical school level, I do feel there is a certain amount of previous education in the sciences (noted above) before you can take biochem, physiology, pharmocology, etc. and understand them well enough to be entrusted with giving a substance that may be lethal to a person. Call me neurotic and unreasonable. We all complain about having to take certian classes in undergrad before we could start med school, but could you imagine taking physiology and patho phys with out physics and basic biology? And then be expected to use what you learned and be responsible for people on drugs that can kill. I know popular culture likes to act as though SSRI's a mainly harmless, but does anyone remember a deadly little syndrome called NMS? which also presents itself medically.

A final piont on why I "whine" instead of helping people. I feel that to discuss a topic openly and look at different view points is a halmark of the medical and any scientific community. Also, discussing the dangers associated with current policy is important. And to ultimately help a person is to educate them and allow that person to come to a decision on his or her own. Is it wrong to discuss why I feel it is dangerous for psychologists and other helping professional to have prescriptive rights? I think not. Nor do I think of it as my peronal time to "whine".

By the way, I love Hilary and will love when she becomes president! Good luck beriberi as you start residency. congrats on finishing med school.

robert g.

 

[Anasazi23]

.....By the way, I love Hilary and will love when she becomes president!
robert g.

Then I also hope you like making 65k a year....

 

[JohnnyVegas]

Let them take over psychiatry.............Let Dr. Phil from Oprah and Dr. Laura become the new psychiatrists..........just don't come complaining to MDs when the idiots that majored in psychology so they could take the easiest multiple choice exams while staying continually drunk in college who don't have a clue or even the slightest interest in neurological science (or any other science for that matter) screw everything up and push back the advancement of psychiatry as well the standard of patient care............



As for the Hillary Clinton supporter.........just keep on supporting people that don't include physicians as part of their constituency and you will be sure to contribute to physicians receiving the short end of the stick every time................

 

[mswphysician]

the discussed above was signed into law yesterday by the governor of Louisiana. see the psychiatry threat on this page for the complete letter.

robert g.

 

[mswphysician]

Then I also hope you like making 65k a year....

please, i was a social worker for 6 years. that is like triple my income (even after grad school)!